Cory Sevin, RN, MSN, Vice President
Pete Leibig, Chief Executive Officer
Eric Boysen, MD, Family Practice Physician
Joy Richardson, RD, CDE, Health Educator
Cecelia Warrick, RN, Clinic Nurse Manager
Teresa Collins, RN, Clinic Nurse Manager

To redesign the diabetes care delivery system for all Type I and II diabetic patients at Clinica Campesina to improve patient self-management skills, glycemic and BP control.

The team set these specific goals:

• 75 percent of diabetic patients with a HbA1c >8 will decrease HbA1c by at least 1 percent. 
• 90 percent of patients will have two HbA1c measurements >3 months apart by September 31, 1999.

In January 1999, the specific goals were modified to include:

• Increase the number of diabetic patients who will have a documented eye exam to 90 percent of the patient population by January 2000.
• Increase the number of diabetic patients who will have a documented foot exam to 90 percent of the patient population by January 2000.

• Percent of diabetic patients who will have two HbA1c measurements at least three months apart
• Percent of diabetic patients with HbA1c>8 who will have decreased HbA1c by at least 1 percent
• Percent of diabetic patients with self-management goals
• Percent of diabetic patients with eye exams
• Percent of diabetic patients with foot exams

System Redesign:

• Changed scheduling system to allow for group scheduling by working with our IS scheduling software and how the schedules print out.
• Revised roles of team members to make better use of all team members with a focus on increasing the roles of the MA in guideline compliance, doing LEAP exams, increasing the role of the nurse in self management and clarifying the role of the RD/CDE.
• Scheduled two cluster visits per month where patient attends group visit and receives a medical visit from Primary Care Provider — one in English and one in Spanish.
• Tested how to schedule a smooth visit so that self management and medical care is received. These evolved into group visits.

• Coordinated efforts and good communication.  Each team member did exactly what they said they would and communicated with rest of the team. Team leader facilitated communication.
• Made the use of the registry, planning for care, guideline compliance and self management support a routine part of care We did this by demonstrating to the providers and their teams that it helped them get good outcomes and decreased the chaos of the day.
• Provided information about care guidelines to patients and actively did follow–up with patients needing care. These small things activated patients into doing their part.
• Linked the diabetes self-management support to the medical visit through our cluster visits, diabetes fairs and group visits. Patients and staff really enjoyed these ways to provide care and, for some patients, it was the only way they received their care.
• Started small and built from there (no failure). We planned PDSA cycles based on the resources (time, energy) that was achievable for the people involved. In this way, the tests were not so overwhelming that they couldn’t get done during a busy day or week.
• Realized that our patients can change. As outcomes for individual patients improved and the population as a whole improved, providers and patients began to feel very hopeful about the possibility of change.
• Realized that little changes do matter. We fully embraced the quick cycle, PDSA tool and did many small PDSA tests.
• Realized that we do not need consensus to change anything. Testing out what actually works and them implementing those things was a welcome relief from sitting in meetings trying to figure out what to do.
• Realized that improving care does not mean more work but rearranging the work that you are doing.
• Realized that we can improve without adding more staff but by being smart about our processes. When all processes are lined up towards a particular aim, more can happen.
• Focused on the patient instead of the provider. In using the Chronic Care Model, the focus changes from the provider needing to have all the answers to the care delivery system and the patient being partners with the provider. Other people get excited to help and the provider doesn’t have to claim control over what they can’t control in the first place.

Cory Sevin, RN, MSN
Vice President
csevin.clinica@hensmann.com